The bulk of the confirmed deaths – 193 at the latest count – were in the small town of Amatrice, where Rita Rosine, 63, wept as she mourned her 75-year-old sister, who was buried under the ruins of her house.

“The situation is worse than in war. It’s awful, awful… they say it will take two days to dig her out because they have to shore up the surrounding buildings,” she told AFP.

“She didn’t deserve to die like that, she was so good.”

As hopes of finding any more survivors in the rubble faded, questions mounted as to why there had been so many deaths in a sparsely-populated area so soon after a 2009 earthquake in the nearby city of L’Aquila left 300 people dead.

That disaster, just 50 kilometres south, underscored the region’s vulnerability to seismic events – but preparations for a fresh quake have been exposed as limited at best.

Prime Minister Matteo Renzi announced on Thursday the launch of a plan to help better prepare Italy for earthquakes.

“Italy should have plan that is not just limited to the management of emergency situations,” he said after a Cabinet meeting.

“(In this area) we are the best in the world, but that’s not enough.”

Renzi admitted that Italy has a difficult task ahead to secure buildings – and its vast collection of historical heritage – against quake damage, but said that modern technology could play a role.

He also stressed that priority would be given to securing “a place to sleep” for those who had lost their homes in the quake.

Giuseppe Saieva, the chief public prosecutor for most of the area affected, said he would be opening an investigation into whether anyone could be held responsible for the disaster.

Culture Minister Dario Franceschini said Thursday that some 293 historical buildings were damaged or destroyed by the quake.

No new survivors

In Amatrice, a 4.3 magnitude aftershock shook the already badly damaged village on Thursday, fuelling fears of fresh collapses which could hamper the rescue operation.

Amatrice normally has a population of around 2,500 but it was packed with visitors when the quake struck as people slept in the early hours of Wednesday.

A total of 215 people have been rescued from the rubble since Wednesday morning. But there have been no reports of survivors being found since Wednesday evening, when eight-year-old Giorgia was rescued 16 hours after being trapped, having been located by a labrador called Leo.

Her parents also survived but her 10-year-old sister did not make it. “I hope Giorgia will be able to forget what she went through,” Angelo Moroni, the head of the team that saved her, told La Repubblica.

The last survivor in L’Aquila was found 72 hours after the quake.

‘What happens tomorrow?’

Hundreds of people spent Wednesday night sleeping in their cars or in hastily-assembled tents, the aftershocks adding to their discomfort.

Mario, a father of two small boys, said he was still in shock. “We slept in the car last night, though with the quakes it was hard to sleep at all,” he told AFP.

“We’ve booked a tent for tonight. But then tomorrow, the next day?”

The extensive damage to lightly-used properties has raised the spectre of some of the smaller hamlets in the region becoming ghost towns.

“If we don’t get help, L’Arquata is finished,” said Aleandro Petrucci, the mayor of Arquata del Tronto, which accounted for 57 of the confirmed deaths to date.

Petrucci said it was impossible to say exactly how many people were in the 13 tiny communities that make up L’Arquata when the disaster struck.

In Pescara del Tronto, which was virtually razed by the quake, there are only four permanently resident families but there could have been up to 300 people there on Wednesday.

Measuring 6.0-6.2 magnitude, the quake’s epicentre was near Amatrice and its shallow depth of four kilometres exacerbated its impact.

It occurred without warning but in an area with a long history of killer quakes.

The Civil Protection agency which is coordinating the rescue effort said that in addition to the dead, 365 people had suffered injuries serious enough to be hospitalised. Several of them are in a critical state.

‘Nothing ever done’

After L’Aquila, the Civil Protection agency made almost one billion euros available for upgrading buildings in seismically-vulnerable areas.

But the take-up of grants has been low – because of form-filling attached, critics say.

“Here in the middle of a seismic zone, nothing has ever been done,” said Dario Nanni of the Italian Council of Architects.

“It does not cost that much more when renovating a building to make it comply with earthquake standards. But less than 20 per cent of buildings do.”

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